What do we know about food allergies in the school?

1. What do we know about food allergies in the school? Christine Szychlinski, MS, APN, CPNP  Manager, Bunning Food Allergy Program at Children’s Memorial Hospital Chicago, IL

2. Definition Adverse reactions to foods are any abnormal reaction associated with ingestion and can include intolerances Food Allergy is different Reaction mediated by the immune system which is rapid in onset and involves allergic symptoms. Any food allergy reaction can be life threatening

3. Food allergy • 6% of young children in U.S. • affects approximately 1 in 25 school-aged children • 4% of adults in U.S. • Increasing prevalence in U.S. • 18% increase between 1997 and 2007 (http://cdc.gov/nchs/data/databriefs/db10.pdf) • Leading cause of anaphylaxis treated in emergency departments

4. Common Allergens Cow’s milk Egg white Peanut Tree nuts Soy Wheat Fish Shellfish

5. Diagnosis  Diagnosis can be made with convincing clinical history supported by testing and/or oral food challenge. • Skin testing supports a reaction but has a 50% false positive rate without a history • Blood based testing can provide a diagnosis with 95% confidence with a very limited number of foods • Milk, egg, peanut and walnut • Cannot predict severity of reaction

6. Treatment There is no cure (yet) for food allergies. The only current treatment is AVOIDANCE.

7. Avoidance  Avoid exposure to allergen • During school day •  While traveling to and from school •  During school-funded events •  While on field trips

8. Avoidance Other issues with avoidance include Cross-contamination Mislabeled foods/unlabeled foods Different practices Developmental readiness of child

9. School is a high risk setting   Accidents happen at school and not always where you may predict • Telephone survey of 132 children indicated 58% had food allergy reactions in the past 2 years •  18% of reactions were in the school setting(Sicherer S JACI 2003) • Data collection over a 2 year time showed majority of reactions occurred in the classroom (McIntyre CL Pediatrics 2005)

10. Impact on the school nurse Telephone survey of 400 school nurses 44% increase in food allergies >33% at least 10 students with food allergy 78% did staff training 74% did guideline development Weiss, C Jrnl of School Nurs 2004 Need for standardized guidelines

11. What are the risks associated with food allergy reactions • ANY FOOD can cause a fatal reaction in an allergic child • Some risk factors for life threatening reactions • a history of a life threatening reaction in the past • asthma • adolescent age group • peanut and/or tree nut allergy • DELAY IN GETTING EPINEPHRINE (Bock A JACI 2001/2007)

12. Managing Food Allergies in School •  Illinois School Code: each school board is required to implement a policy for the management of students with life-threatening food allergies by January 1, 2011 • Use the "Guidelines for Managing Life-threatening Food Allergies in Illinois Schools“ to create school policies and best practiceswww.isbe.net

13. Step one Identifying the child with food allergy each child identified by a parent as having food allergy must have an Emergency Action Plan (EAP) signed by a licensed health care provider (LHCP) The EAP includes the child’s allergy foods and what medications should be used in an emergency situation The form available for use also contains parental treatment authorization and other information necessary for the school staff

16. Emergency Action Plan (EAP):  Auto injectable Epinephrine  EAP provides: Permission to self-administer Medication authorization and dose Parent's consent for the school to administer medication A list of staff members trained Where auto-injectors stored (including a backup storage)

17. Step two An Individualized Health Care Plan is created for the child based on the recommendations of the LHCP Participants may include parents, school administration, school health personnel, teachers, custodial staff, kitchen staff, social work/special education The child’s day should be considered from the time they arrive in school (or are on the school bus) until the time they are returned to the care of their parents or guardians This should include after school activities and may need to include activities that use school property that do not directly involve the child

18. How risky is the environment Studies have looked peanut allergen in the school and these findings can help with decision making

19. How does research help us in the school setting • How safe is the average school environment? • Testing of 60 sites in 7 schools after routine cleaning had one positive finding for peanut (Perry TT JACI 2004) • How can you effectively remove peanut from hands? • Most cleaning methods worked except plain water and hand sanitizer • How can you effectively remove peanut from surfaces? • Most cleaning methods worked except dishwashing liquid (Perry TT JACI 2004)

20. The environment • Studies show that it is possible to keep a school environment safe for food allergen if attention is paid to details • Remembering: • Allergen must be physically removed • Plans in place to minimize cross contamination • Use the right methods • The developmental level of the child

21. Airborne peanut Airborne • Activities included eating peanut products, open jars of peanut butter, shelling peanuts and walking on the shells, opening bags of unshelled peanuts while other had samples collected via personal air monitors and area samples • No detectable peanut allergen found(Perry TT JACI 2004) • Double blind placebo controlled randomized exposure to peanut contact and inhalation • No respiratory reactions • 10/30 had contact reaction(Simonte SJ JACI 2003)

22. Prevent a Reaction:So what do those studies tell us? • Exposure to food allergens by touch or inhalation is unlikely to cause a life-threatening reaction (Simonte SJ JACI 2003) • However, risk of ingestion (and reaction) if child touches allergen and then place fingers in or near mouth or nose  • Food allergy precautions cannot be one size fits all • Younger children will require more safe guards

23. FALCPA 2004

24. What about food labeling Do allergic consumers avoid those foods? • Less likely to avoid in 2006 (75%) versus 2003 (85%) • More avoid “may contain” than “shared facility” Do foods with advisory labeling contain peanut? • Detectable peanut protein in 10% of foods • 7% with levels which could cause reaction • “may contain” 2/51 “shared facility” 7/68(Hefle SL JACI 2007)

25. Food labeling Looked at foods with advisory labeling for milk, egg and peanut and also similar foods with no allergen disclosure Peanut more likely to be found in a product with advisory labeling (not milk or egg) Milk more likely to be found in products from small vs. large manufacturers (not egg or peanut) 7 contaminated products without advisory labeling were from 5 companies and only 1 large company Overall 5.1% of foods with advisory labels from small companies tested positive and 0.75% from large companies (Ford LS JACI 2010)

26. What should happen in schools • Read labels and strictly avoid • allergens stated on ingredient list • allergens stated on advisory statements • foods not labeled • Guidelines should acknowledge that food allergic families have different practices

27. Keys to allergen avoidance Control of environment Identify all food including food used in the curriculum Consistent cleaning practices Minimizing risk according to child’s developmental abilities Use of the EAP in the development of an IHCP Everyone involved with the child and the child’s environment must be familiar with what is needed Keep in mind social consequences of food allergy and be alert for bullying and increased risk of isolation

28. Accidents happen It is estimated that a child will have an accidental ingestion of one of their food allergens about every 5 years The setting for these accidents according to some studies are allergens specific with milk being the most common allergen accidentally ingested at home School is not an uncommon site for accidental ingestions Increased risk when routine is broken Some children may not recognize the early symptoms of an allergic reaction Some children may be more fearful of admitting a mistake

29. Reactions can include

30. Allergic Reaction: What a Child Might Say or Do Say • “My tongue (or mouth) itches” • “My tongue is hot/burning” • “My mouth feels funny” • “There’s something stuck in my throat” • “It feels like there are bugsin my ears” • “This food is too spicy” Do • Put their hands in their mouths • Pull or scratch at their tongues • Drool • Hoarse cry or voice • Slur words • Become unusually clingy

31. All staff must be able to recognize a reaction Early recognition saves lives. Signs and symptoms can vary from mild to severe, life-threatening and can change quickly. Those with more severe reactions respond to lower amounts.(Wensing M JACI 2002)

32. Recognize a reaction: Anaphylaxis • The medical diagnosis for a severe reaction. • Symptoms rapid in onset and severe. • Involves the most dangerous symptoms including but not limited to: breathing difficulties and a drop in blood pressure (shock). • Always a risk of death, even if treated appropriately.

33. Allergic reaction: Respond Follow the Food Allergy Emergency Action Plan prescribed by licensed health care provider Take all symptoms seriously Do not delay in giving epinephrine when required Safe and simple to use If epinephrine given, call 911

34. Autoinjectable epinephrine • Expiration date • Must be readily available • Call 911 after administering • Train and retrain

35. Managing Food Allergies in School: Summary  Create a safe environment Prevent a reaction: Avoidance Know the IHCP for your student Recognize a reaction: Know the signs and symptoms Respond to an allergic reaction: Know the EAP for your student. Respond quickly. Practice emergency response drills

36. Thank you! Questions? Useful websites: www.foodallergyinitiative.org www.foodallergy.org www.childrensmemorial.org/FACE